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Each year unhealthy diets are linked to 11m deaths worldwide a global study concludes

Red and processed meat not only cause disease and premature death from chronic non-communicable diseases (NCD) but also put the planet at unnecessary risk

Evidence suggests that the health benefits of a Mediterranean diet reduces the risk of NCDs and is better for the Planet

Eat like Greeks, live healthier lives and save our planet

Findings of an international research project about the relationship between diet and chronic diseases are reported in a paper entitled, “Health effects of dietary risks in 195 countries 1990-2017. A systematic analysis for the Global Burden of Disease Study 2017”, which is published in the April 2019 edition of The Lancet. The paper suggests that millions of people throughout the world consume an unhealthy diet comprised of too much processed meat, sodium and sugar and too little plant-based foods, such as fruits and vegetables, whole grains and nuts. This results in a significant increase in the prevalence of chronic non-communicable diseases (NCD) such as coronary heart disease, cancer and diabetes and each year causes some 11m avoidable deaths worldwide - 22% of all adult deaths: 10m from cardiovascular disease, 913,000 from cancer and some 339,000 from type-2 diabetes. According to the paper’s authors, “Asuboptimal diet is responsible for more deaths than any other risks globally, including tobacco smoking, highlighting the urgent need for improving human diet across nations”.

In this Commentary

This Commentary reviews evidence of recent large-scale epidemiology studies, which suggest that “you are what you eat”. Not only do unhealthy diets cause ill health and premature death for millions, they also harm the environment and push the Earth beyond its planetary boundaries. All the studies we describe conclude that we know the answer to this vast and escalating health problem: eat like Greeks or indeed the Japanese. Notwithstanding, changing the way populations collectively eat is a massive challenge facing governments, healthcare systems and individuals.

The Global Burden of Disease project

The Lancet paper’s findings described above are based on the Global Burden of Disease (GBD) enterprise, which is one of the world’s largest scientific collaborative research projects, which was started in the early 1990s by the World Bankto measure the impact of disability and death from hundreds of diseases worldwide. Over the past two decades its work has grown, and the endeavour has become institutionalized at the World Health Organization (WHO). Today, the GBD project is an international consortium of more than 3,600 researchers, its findings are updated annually and they influence health policy throughout the world.

Red meat and bowel cancer

Findings of a more narrowly focussed but nonetheless significant study, published in the April 2019 edition of the International Journal of Epidemiology warn that red-processed meat consumption is linked with bowel cancer. According to Tim Key, the study’s co-author, Professor of Epidemiology and Deputy Director at Oxford University's Cancer Epidemiology Unit, “Results strongly suggest that people who eat red and processed meat four or five times a week have a higher risk of developing bowel cancer than those who eat red and processed meat less than twice a week . . . . There’s substantial evidence that red and processed meat are linked to bowel cancer and the World Health Organization classifies processed meat as ‘carcinogenic’ and red meat as ‘probably carcinogenic’”. Notwithstanding, Key warns that, “Diet studies are problematic because those who take part often either forget what they have eaten or fail to tell the truth”. Key also suggests that, “Most previous research [on diet and cancer] looked at people in the 1990s or earlier and diets have changed significantly since then”.

Chronic non-communicable diseases

Chronic non-communicable diseases (NCD) are largely caused by humans and are therefore preventable. Notwithstanding, they account for more than 70% of all deaths globally and emergent NCDs pose significant systemic challenges for both nation states and individuals. Forty percent of all adults in the world are overweight and 1.4bn suffer from hypertension: both critical risk factors of NCDs. In 2016, 18m people died from cardiovascular disease (CVD), representing 31% of all global deaths. In the US an estimated 92m adults are living with CVD. By 2030, 44% of the US adult population is projected to have some form of CVD. There are around 7m people living with heart and circulatory disease in the UK. Worldwide some 0.5bn people have diabetes and in 2018 there were 17m new cases of cancer worldwide. Although there are some encouraging signs associated with the slowing of the prevalence rates of NCDs globally, prevalence of NCDs is expected to rise because of population growth and aging, misaligned healthcare policies and institutional inertia.

The paradox of food insecurity and obesity

Paradoxically, food scarcity and obesity are both forms of malnutrition and represent a vast and escalating burden on the worlds limited and diminishing resources. This is because food insecurity can contribute to people being overweight and obese. Nutritious fresh foods often tend to be expensive, so when household resources for food become scarce, people choose less expensive foods that are often high in calories and low in nutrients. As a result, adult obesity rates continue to rise each year, from 11.7% in 2012 to 13.2% in 2016. In 2017 the World Health Organization estimated that more than one in eight adults, or more than 672m people in the world, were obese and 2bn were classified as overweight. A report from the Center for Strategic and International Studies, a think-tank based in Washington DC, US, suggests that worldwide each year, "Malnutrition costs US$3.5trn, with overweight- and obesity-related NCDs, such as cardiovascular disease and type 2 diabetes, adding US$2trn”.

The EAT-Lancet Commission on Food, Planet and Health

Not only do unhealthy diets result in NCDs and premature death, but they also harm the environment. The dual aspects of unhealthy diets causing disease and harming the planet are described in research conducted by the EAT-Lancet Commission on Food, Planet and Health, and reported in the January 2019 edition of The Lancet.

EAT is an independent non-profit organisation based in Oslo, Norway, dedicated to food-system reform, which collaborated with TheLancet. The report took 3-years to complete and brought together 37 world-renowned scientists from 16 countries with expertise in health, nutrition, environmental sustainability, food systems, economics and political governance; and tasked them with reaching a consensus that defines a sustainable “healthy planetarydiet”, which the authors suggest approximates a Mediterranean diet, see below.

The EAT-Lancet research, financed by the Wellcome Trust,analysed the diets of people in 195 countries using survey data, as well as sales data and household expenditure data to estimate the impact of unhealthy diets on the risk of death and morbidity from NCDs. The Commission’s authors provide a comprehensive picture of the consumption of 15 dietary factors across nations and quantify the potential impact of suboptimal intake of each dietary component on NCD mortality and morbidity among 195 countries. Also, researchers calculate mortality related to other risk factors,such as smoking and drug use, at the global level.

The EAT-Lancet Commission’s report has its critics. One is the UK’s National Farmers’ Unionwhose Vice President Stuart Roberts said, “Scientific communities agree that red meat plays a vital role in a healthy, balanced diet as a rich source of essential nutrients, minerals, amino acids and protein. It is overly simplistic to target one food group for a significant reduction in consumption, and it ignores its medically accepted role as a key part of a healthy, balanced diet . . . It is clear that climate change is one of the greatest challenges of our time and British farmers are continuing to take action. A combination of policies and practises will be needed to enable farmers to meet their ambitions, but we must not forget the impact of a changing climate on food production”.

Benefits of red meat

Roberts is right to point out that red meat has health benefits. Heme iron, which is found in red meat (also in poultry, seafood and fish) is easily absorbed by your body and is a significant source of your dietary iron. Red meat also supplies you with vitamin B12 and zinc. The former is required for red blood cell formation, neurological function and DNA synthesis, and the latter helps stimulate the activity of at least 100 different enzymes and helps to keep your immune system working effectively. Further, red meat provides protein, which helps to build your bones and muscles. People have been eating meat for millennia and have developed digestive systems well equipped to handle it.

Notwithstanding, the overwhelming majority of red meat consumed in the developed world today is processed: raised in a factory environment, fed grain-based feed and given growth-promoting hormones and antibiotics and some animals, after being slaughtered, are further treated with nitrates, preservatives and various chemicals. The findings of all three studies described above demonstrate the harm of eating too much red and processed meat and stress the health and environmental benefits of a Mediterranean diet.

An urgent challenge

According to the EAT-LancetCommission’s authors, “Providing healthy diets from sustainable food systems is an urgent and pressing challenge”. As the global population continues to grow - projected to reach 10bn by 2050 - and become wealthier, there is expected to be a concomitant increase in unhealthy diets comprised of red meat, processed food and sugar. To address this vast and escalating challenge, populations will need to combine significant dietary changes with enhanced food production and reduced food waste.

The impact of food waste

Before broaching some of the challenges associated with changing the way we eat collectively let us briefly describe the magnitude and effect of food wastage. According to the United Nation’s(UN) 1.3bn tonnes of food are wasted every year, which is about 33% of the total produced. The cost of global food losses and waste amounts to roughly US$990bn and yet some 800m people worldwide do not get enough to eat and 2bn people are overweight.

Further, food wastage is estimated to release the equivalent of 3.3bn tonnes of CO2 into the atmosphere each year. The total volume of water used annually to produce food that is lost or wasted (250km³) is equivalent to three times the volume of Lake Geneva. Similarly, 1.4bn hectares of land - 28% of the world's agricultural area - is used to produce food that is lost or wasted. And agriculture is responsible for a majority of threats to at-risk plant and animal species tracked by the International Union for Conservation of Nature.

Changing what we eat and how we produce food will save lives and the planet

According to Alan Dangour, Professor in Food and Nutrition for Global Health at the London School of Hygiene & Tropical Medicine(LSHTM), “The EAT-Lancet Commission’s analysis demonstrates that shifts in our diets can have enormous beneficial effects on health and also substantially reduce our impacts on the environment. This significant ‘win-win’ for health and the environment is not a new finding, but this analysis, which for the first time defines environmental boundaries for the food system, is the most advanced ever conducted”.

In a similar vein, Tara Garnett, a contributor to the EAT-LancetCommission and a principal investigator of another research project on the future of food, also suggests that there’s nothing new in the Commission’s report but its fundamental message is that, “We’re not going to address our environmental problems unless we address the problems caused by the food system and we’re not going to address the problems caused by the food system unless we shift the way we eat collectively and globally”.

Rebalancing unhealthy diets is a significant challenge

Changing how we eat collectively, which Garnett and others suggest is necessary to reduce NCDs and enhance our environment, is not going to be easy. This is because it would involve cutting by half our consumption of red meat, processed food and sugar, and doubling our consumption of vegetables, fruit, pulses and nuts. For people living in the US and UK it would be even more challenging because the EAT-Lancet Commission ranks the US 43rd and the UK 23rd for their respective unhealthy diets out of the 195 nations in its study. It is suggested that in order to adopt a healthy diet Americans would need to eat 84% less red meat and six times more beans and lentils, and British people would have to eat 77% less red meat and 15 times more nuts and seeds.

Countries with the lowest rates of diet-related deaths are Israel, France, Spain and Japan. The highest rates are reported to be found in Uzbekistan, Afghanistan and the Marshall Islands. According to the Commission’s authors a Mediterranean-type-diet, “is what we should all be eating if we are concerned about our health and that of the planet”: it lowers the incidences of heart disease, diabetes and cancer, enables more environmentally helpful use of land and reduces carbon emissions.

The Mediterranean diet

The Mediterranean diet has been around for millennia and tends to be more of a lifestyle than a diet. It entails significantly lower amounts of beef, dairy products, sugar, soft drinks, pastries and processed foods; higher amounts of fish, fruit, nuts and salads, and no pasta, French fries and pastries. Unlike fashionable commercial diets associated with the weight management market, the Mediterranean diet does not have a set of specific rules that focus on losing weight, but instead emphasises eating fresh food over a lifetime. Also, the Mediterranean diet has been well studied. Research suggests that it is associated with a reduced risk of heart disease and cardiovascular mortality because of its significantly lower amounts of oxidized low-density lipoprotein (LDL) cholesterol, (the "bad" cholesterol) which is more likely to build up deposits in your arteries. Other benefits include reduced incidence of cancer, Parkinson's and Alzheimer's diseases. Further, women who follow a Mediterranean diet have a reduced risk of breast cancer.

The PREDIMED study

Findings of a landmark clinical trial, entitled “Primary Prevention of Cardiovascular Disease with a Mediterranean Diet”, was published in the June 2013 edition of the New England Journal of Medicine (NEJM). Popularly known as the PREDIMED study (Prevencion con Dieta Mediterranea), it tested the impact of two Mediterranean diets on cardiovascular risk. The first included a Mediterranean diet plus 30 grams of mixed nuts per day and the second was a Mediterranean diet plus at least four tablespoons a day of extra-virgin olive oil. The two diets were then compared to a low-fat diet, which is popularly advocated and pursued in the US and UK and among other developed nations and discourages the consumption of any high-fat items such as butter, cheese, oil, meats and pastries.

The low-fat diet

In the 1960s low-fat diets as opposed to high-fat, high-cholesterol diets were considered to promote heart health. By the late 1980s and early 1990s the low-fat diet was advocated by doctors, policy makers, the food industry and the media although there was no hard evidence to demonstrate it prevented heart disease and promoted weight loss. Notwithstanding, the low-fat-diet became an important part of the large and rapidly growing global weight management market, which is valued at some US$169bn and projected to grow at a CAGR of 2.4% and reach a value US$279bn by 2023. Interestingly, in the 80s and 90s, as the low-fat diet became an institution in the US and UK so the prevalence of overweight and obesity increased. Only recently has the low-fat diet been challenged as scientific evidence about fats increased.

A significant study with some methodological challenges

The PREDIMED study involved 7,447 people between 55 and 80 who were free from heart disease, came from 11 study centres across Spain and were randomly assigned to one of the three diets for five years. Findings suggested that the Mediterranean diet significantly reduced the risk of heart attack, stroke and cardio-vascular mortality compared to the low-fat diet. However, researchers discovered flaws with the study’s methodology and withdraw their findings. Most significantly, not all participants were randomly assigned to their diet and this could have influenced their findings.

Revised study of the Mediterranean diet

Researchers adjusted their methodology for its "irregularities in the randomization procedures" and published “new” findings in the June 2018 edition of the New England Journal of Medicine(NEJM), which confirmed the health benefits of a Mediterranean diet for adults at high risk for heart disease and found that the Mediterranean diet, plus olive oil or nuts, reduced risk for heart events by 30% compared to a low-fat diet. Lead author Miguel Ángel Martínez-González suggested that only about 10% of participants were affected in their earlier study reported in 2013, and their 2018 analysis made researchers, "More convinced than ever of the robustness of the protection by the Mediterranean diet against cardiovascular disease”. According to Jeffrey Drazen, editor-in-chief of the NEJM, "Medical professionals and their patients can use the republished information with confidence". While reaction to the study’s initial findings was disappointing, experts are encouraged by the adjusted findings, which confirm the heart-health benefits of a Mediterranean diet, particularly in adults at high risk for heart disease. Notwithstanding, experts emphasise the significance of sustaining a healthy diet over time.

The health benefits of the Japanese diet

The Mediterranean diet is not the only diet, which has proven to have significant health benefits. The Japanese diet, which is low in calories and saturated fat and high in nutrients, especially phytonutrients such as antioxidants and flavonoids, found in different coloured vegetables, also has considerable health benefits. Findings of two studies; one published in the April 2017 edition of PLOS.ONE, and another published in the March 2016 edition of the British Medical Journal demonstrate that, closer adherence to a Japanese diet resulted in a significantly lower risk of death from NCDs and in particular from cardiovascular disease or stroke. Japan has the highest life expectancy of any country: 90 years for women and 84 for men. Okinawa, in southernmost Japan, has the highest number of centenarians in the world as well as the lowest risk of age-related diseases such as cancer and heart disease. There are nearly 800 centenarians in Okinawa, which has a population of 1,368,000. The diet of the Okinawan people has been little influenced by the dietary changes influenced by western culture, which also have been seen in more urban Japan.

Takeaways

All the research findings we describe in this Commentary confirm the adage that, “You are what you eat”. Nutrients from the food you eat provide support for all the cells in your body, which have different “shelf lives”. For example, your skin cells live for about a month and your red blood cells for about four months. So, your body is constantly regenerating new cells to replace those that have “expired”. The health of your new cells is partly determined by how well you have been eating. A diet high on processed red meat and low on nutrients does not help in this regeneration process. But a nutrient rich, whole food diet can help to build your cells so that they work better to help you recover from common illnesses and the wear-and-tear of everyday life and make you less susceptible to disease.

Although our concern about healthy eating has intensified in recent years, the phrase, “you are what you eat” is not new. In 1826 Anthelme Brillat-Savarin wrote in Physiologie du Gout, ou Meditations de Gastronomie Transcendante, "Dis-moi ce que tu manges, je te dirai ce que tu es" [Tell me what you eat, and I will tell you what you are]. However, the phrase did not emerge in English until the 1920s when nutritionist Victor Lindlahr, who believed that food controls health, developed the Catabolic Diet. According to Lindlahr, "Ninety per cent of the diseases known to man are caused by cheap foodstuffs. You are what you eat". And in 1942, he published a book entitled, “You Are What You Eat: how to win and keep health with diet”. Eat like the Greeks, live healthier lives and save our planet.

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Bridging the gap between medical science and policy to reduce the biggest 21st century healthcare burden

In November 2018 the Mayor on London Sadiq Khan,announced that junk food adverts will be banned on all London transport from February 2019 in an attempt to reduce the “ticking time bomb” of childhood obesity in the city.

London has one of the highest obesity rates in Europe with some 40% of 10 to 11-year olds either overweight or obese, with children from more deprived areas disproportionately affected. Obesity is a common and costly source of type-2 diabetes (T2DM), which is much more aggressive in youngsters and complications of the condition - blindness, amputations, heart disease and kidney failure - can present earlier. What is happening in London and the UK is replicated in varying degrees in cities and nations throughout the world: there is a global epidemic of obesity and T2DM, which together is often referred to as ‘diabesity’.

The “good” news is that at the same time Khan announced the advertising ban, the UK’s national news outlets were reporting the product of four decades of scientific research, which suggested that T2DM could be reversed by a liquid diet of 800-calories a day for three months.

Although this offers hope for millions of people, an unresolved challenge is whether this simple and cheap therapy will be implemented effectively to significantly dent the burden of diabesity, which arguably is the biggest healthcare challenge of the 21st century.

In this Commentary

We describe some of the research behind the news reports about the therapy to reverse T2DM. Although the scientists’ innovative solution of a low-calorie liquid diet has been adopted enthusiastically by some healthcare providers and organizations specifically set up to dent the burden of diabesity, it is questionable whether the gap between science and policy can be bridged. This, we suggest, is because the prevalence of diabesity is growing at a significantly faster rate than the effect of programs to prevent and reduce the condition.

Obesity and T2DM

Obesity, which is a significant risk of T2DM, is a complex, multifaced condition, with genetic, behavioural, socioeconomic and environmental origins. Diet and sedentary lifestyles may affect energy balance through complex hormonal and neurological pathways that influence satiety. Also, urbanization, the food environment and the marketing of processed foods are contributory factors to becoming overweight and obese. Notwithstanding, the main driver of weight gain is energy intake exceeding energy expenditure.

T2DM is a chronic, progressive metabolic disease, which until recently has been perceived as incurable. Although genetic predisposition partly determines the condition’s onset, being overweight and obese are significant risk factors. Generally accepted clinical guidelines to treat the condition is to reduce glycated haemoglobin (HbA1c) - blood sugar (glucose) - levels. The HbA1c test assesses your average level of blood sugar over the past two to three months. The normal range for HbA1c is 4% to 5.9%. In well-controlled diabetic patients HbA1c levels are less than 6.5% or 48mmol/moll. High levels of HbA1c mean that you are more likely to develop diabetes complications, such as serious problems with your heart, blood vessels, eyes, kidneys, and nerves. T2DM is treated primarily with drugs and generic lifestyle advice, but many patients still develop vascular complications and life expectancy remains up to six years shorter than in people without diabetes.

Obesity

The Organisation for Economic Co-operation and Development’s (OEDC) 2017 Health at a Glance Reportwarned that obesity in the UK has increased by 92% in the past two decades. Two-thirds of the UK’s adult population are overweight and 27% have a body mass index (BMI) of 30 and above, which is the official definition of obesity. In 2017 there were 0.6m obesity-related hospital admissions in the UK, an 18% increase on the previous year. Each year, obesity cost NHS England in excess of US$10bn in treatment alone.

A 2018 World Health Organization (WHO) report suggests that obesity globally has almost tripled since 1975. In 2016, more than 1.9bn adults, 18 years and older, were overweight. Of these over 650m were obese. According to a 2018 WHO report on childhood obesity 41m children under the age of 5 were overweight or obese in 2016 and over 340m children and adolescents aged 5-19 were overweight or obese.

Bad diets

Diets in the UK, and in most wealthy advanced industrial economies, tend to have insufficient fruit and vegetables, fibre and oily fish and too much added sugar, salt and saturated fat. Rising consumption of processed food and sugary drinks are significant contributors to the global obesity epidemic. A typical 20-ounce soda contains 15 to 18 teaspoons of sugar and upwards of 240 calories. A 64-ounce cola drink could have up to 700 calories. People who consume such drinks do not feel as full as if they had eaten the same number of calories from solid food and therefore do not compensate by eating less. While healthy diets are challenging for most populations, low income levels and poor education are associated with less healthy diets.

Almost 4.6m people in the UK and 30m Americans are living with diabetes: 90% of whom have T2DM. It is estimated that 12.3m people in the UK and some 70m in the US are considered pre-diabetic, which is when you have high blood glucose levels, but not high enough to be diagnosed with diabetes. The first WHO Global report on diabetes published in 2016 suggests that 422m adults (1 in 11) worldwide are living with the condition, which has quadrupled over the past three decades. The International Diabetes Federation (IDF) estimates that this figure will rise to 642m by 2040. A further challenge is the undiagnosed. A December 2017 paper in Nature Reviews: Endocrinologysuggests 46% of all cases of diabetes globally are undiagnosed and therefore at enhanced risk of complications. Until complications develop, most T2DM patients are managed within primary care, which constitutes a significant part of general practice activity. International data suggest that medical costs for people with diabetes are two to threefold greater than the average for people without diabetes.

T2DM treated but not cured

The most common therapy for T2DM patients who are overweight is metformin, which is usually prescribed when diet and exercise alone have not been enough to control your blood glucose levels. Metformin reduces the amount of sugar your liver releases into your blood and also makes your body respond better to insulin. Insulin is a hormone produced by your pancreas that allows your body to use sugar from carbohydrates in food that you eat for energy or to store glucose for future use. The hormone helps to keep your blood sugar levels from getting too high (hyperglycaemia) or too low (hypoglycaemia). Metformin does not cure T2DM and does not get rid of your glucose, but simply transfers your excess sugar from your blood to your liver. When your liver rejects your excess sugar, the medicine passes the glucose onto other organs: kidneys, nerves, eyes and heart. Much of your excess sugar gets turned into fat and hence you become overweight or obese. T2DM has long been understood to progress despite glucose-lowering therapy, with 50% of patients requiring insulin therapy within 10 years. This seemingly inexorable deterioration in control has been interpreted to mean that T2DM is treatable but not curable. Research briefly described in this Commentary suggests that T2DM can be beaten into ‘remission’, but it requires losing a lot of weight and keeping it off.

Reversing T2DM

Over the past decade a series of studies, led by Roy Taylor, Professor of Medicine and Metabolism at the University of Newcastle, England and colleagues from Glasgow University have explored the notion that losing weight could be the solution for controlling T2DM and lowering the risk of debilitating and costly complications.

Findings of a study in the December 2017 edition of the Lancet, suggested that nearly 50% of people living with T2DM who had participated in a low-calorie liquid diet of about 800 calories a day for three to five months had lost weight and had reverted to a non-T2DM state. The study was comprised of 298 adults between 20 and 65 who had been diagnosed with T2DM within the past six years drawn from 49 primary care practices in Scotland and Tyneside in England. Half of the practices put their patients on the low-calorie diet, while the rest were in a control group and received the standard of care of anti-diabetic medicines to manage their blood glucose levels. About 46% of 149 individuals with T2DM who followed a weight loss regimen achieved ‘remission’, which the study defined as a HbA1c of less than 6.5% after one year. Only 4% of the control group managed to achieve ‘remission’. ‘Remission’ rather than ‘cure’ was used to describe the reversal of T2DM because if patients put weight back on, they may become diabetic again. Results improved according to the amount of weight lost: 86% of those who lost more than 33 pounds attained remission, while 57% of those who lost 22 to 33 pounds reached that goal.

Another paper by Taylor and his colleagues published in the October 2018 edition of Cell Metabolism,examined reasons why substantial weight loss - (15kg) in some patients - produces T2DM remission in which all signs and symptoms of the condition disappear, while in other patients it does not. Using detailed metabolic tests and specially developed MRI scans, Taylor observed that fat levels in the blood, pancreas and liver were abnormally high in people with T2DM. But after following an intensive weight loss regimen, all participants in the study were able to lower their fat levels. As fat decreased inside the liver and the pancreas, some participants also experienced improved functioning of their pancreatic beta cells, which store and release insulin, controls the level of sugar in their blood and facilitates glucose to pass into their cells as a source of energy. The likelihood of regaining normal glucose control depends on the ability of the beta cells to recover. But, losing less than 1gm of fat from your pancreas through diet can re-start your normal production of insulin and thereby reverse T2DM.

“The good news for people with T2DM is that our work shows that you are likely to be able to reverse T2DM by moving that all important tiny amount of fat out of your pancreas. At present, this can only be done through substantial weight loss,” says Taylor.

While a significant proportion of participants in Taylor’s study responded to the weight loss program and achieved T2DM remission, others did not. To better understand this, researchers focused on 29 participants who achieved remission after dieting and 16 who dieted but continued to have T2DM. Taylor and his colleagues observed that people who were unable to restart normal insulin production had lived with T2DM for a longer time than those that could. Individuals who had lived with T2DM for an average of 3.8 years could not correct their condition through weight loss, while those who had the condition for an average of 2.7 years were able to regain normal blood sugar control.

“Many [patients] have described to me how embarking on the low-calorie diet has been the only option to prevent what they thought - or had been told - was an inevitable decline into further medication and further ill health because of their diabetes. By studying the underlying mechanisms, we have been able to demonstrate the simplicity of T2DM and show that it is a potentially reversible condition. but commencing successful major weight loss should be started as early as possible,” says Taylor.

Taylor and his colleagues describe their research findings as “very exciting” because “they could revolutionise the way T2DM is treated”, but caution that a series of management issues will need to be overcome before their therapy becomes common practice. This includes, (i) familiarizing primary care doctors and T2DM patients with the treatment regimen, (ii) establishing a generally accepted standard for what actually constitutes “remission”. Taylor and colleagues recommend “remission” to be when a patient has not taken diabetes medicines for at least two months and then has two consecutive HbA1c levels, taken two months apart, which are less than 6.5%. Researchers also recommend that data on T2DM reversal rates should be routinely collected, stored, analysed and reported.

Notwithstanding, the ‘elephant in the room’ is the vast extent of diabesity, the eye-watering rate at which it is growing and the general ineffectiveness of policy makers and prevent programs to dent the burden. Research findings presented at the 2018 European Congress on Obesity in Vienna emphasize the magnitude of the problem. If current trends continue, almost a quarter (22%) of the world’s population will be obese by 2045 (up from 14% in 2017), and 12% will have T2DM (up from 9% in 2017). Findings also suggest that in order to prevent the prevalence of T2DM from going above 10% by 2045, global obesity levels must be reduced by 25%. The problem is no less grave at the national level. For example, in the UK, if current trends continue obesity will rise from 32% today to 48% in 2045, while diabetes levels will rise from 10.2% to 12.6%, a 28% rise. This is unsustainable. Here’s the challenge for policy makers.

To stabilise UK diabetes rates over the next 25 years at 10%, which is high and extremely costly, obesity prevalence must fall from 32% to 24%. Similarly, in the US, if current trends continue over the next 25 years, then to keep diabetes rates stable over the same period, obesity in the US would have to be reduced by 10%: from 38% today to 28%.

Takeaways

Taylor and his colleagues have delivered a simple and cheap solution to one of the biggest burdens of the 21st century. But unless there is effective strategy to implement this solution the four decades of research undertaken by Taylor and his colleagues will be wasted. Previous Commentaries have described the vast and crippling burden of diabesity and the failure of well-funded programs to make any significant dent in this vast and escalating burden, which is out of control. We have suggested, this is partly because, at the operational level, programs have tended to be predicated upon inappropriate, old fashioned, 20th century organizational methods and technology and focused on “activities” rather than “outcomes”. At a policy level, government agencies have systematically failed to slow the rise of processed food becoming the “new tobacco”. Most UK endeavours to reduce the burden of diabesity are like putting up an umbrella to fend off a tsunami. This must change if we are to harness and effectively deploy the research findings of Professor Taylor et al.

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16% of cancers in the UK are linked to excess weight and type-2 diabetes (T2DM)

62% of adults are overweight or obese in England

4m people are living with T2DM in the UK and another 12m are at increased risk of T2DM

Prevalence rates of both obesity and T2DM are rising

Ineffective prevention initiatives should be replaced with effective ones if we are to dent the vast and escalating burden of obesity, T2DM and related cancers

Public health officials, clinicians and charities need to abandon ineffective inertia projects embrace innovation and look to international best practice

Excess weight and type-2 diabetes linked to 16% of cancers in the UK

Being overweight and living with type-2 diabetes (T2DM) is a potentially deadly combination because it significantly increases your risk of cancer and contributes to the projected increase in cancer cases and deaths in the UK. Findings of a study published in the February 2018 edition of The Lancet Diabetes and Endocrinologysuggest that a substantial number of UK cancer cases are linked to a combination of excess body mass index (BMI) and T2DM, which here we refer to as diabesity. To lower the growing burden of cancer associated with diabesity, more effective prevention strategies will be required. To achieve this, clinicians, public health officials and charities will need to reappraise their current projects, innovate, and learn from international best practice.

BMI, obesity and T2DM defined

Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults. It is a person's weight in kilograms divided by the square of his height in meters (kg/m2). Overweight is a BMI greater than or equal to 25; and obesity is a BMI greater than or equal to 30. T2DM is a long-term metabolic disorder characterized by high blood glucose (sugar), insulin resistance, and relative lack of insulin. Insulin is a hormone produced in the pancreas, which is used by the body to manage glucose levels in the blood and helps the body to use glucose for energy.

In this Commentary

This Commentary describes the findings of a study reported in a 2018 edition of The LancetDiabetes and Endocrinology, which suggests that current initiatives to prevent and reduce the burden of diabesity are ineffective. Previous Commentaries have described the Mexican Casaludand the Oklahoma City projects, which have successfully reduced obesity and type-2 diabetes (T2DM). These represent innovative international best practice, which have been largely gone unnoticed by the UK’S diabetes establishment. Also, we describe findings of a study published in the May 2017 edition of Scientific Reports, which suggests that although Google trend data can detect early signs of diabetes, they are underutilized by traditional diabetes surveillance models. The prevalence of diabesity in the UK is significant and growing so fast that public health officials, clinicians and charities will have to replace failing inertia projects with more effective ones if they are to dent the growing burden of cancer linked to a combination of obesity and T2DM.

The Lancet Diabetes and Endocrinology study

A comparative risk assessment study published in The Lancet Diabetes and Endocrinology was carried out by researchers from Imperial College London, Kent University and the World Health Organization. It suggests that in 2012, 5.6% of all cancers worldwide were linked to the combined effect of obesity and diabetes, which corresponded to about 0.8m new cancer cases. 25% of these account for liver cancer in men, and 38% account for endometrial cancer, which affects the lining of the womb in women.

Obesity T2DM and cancer

There is a close association between obesity and T2DM. The likelihood and severity of T2DM are closely linked with BMI. If you are obese your risk of T2DM is 7-times greater than someone with a healthy weight. If you are overweight your risk of T2DM is 3-times greater. Whilst it is known that the distribution of body fat is a significant determinant of increased risk of T2DM, the precise mechanism of association remains unclear. It is also uncertain why not all people who are obese develop T2DM and why not all people with T2DM are either overweight or obese. Also, the link between obesity and some cancers is well established. More recently, researchers have linked diabetes to several cancers, including liver, pancreatic and breast cancer. The 2018 Lancet Diabetes and Endocrinologystudy described in this Commentary is the first time anyone has calculated the combined effect of excess BMI and T2DM on cancer worldwide.

Findings

According to the Lancet study’s findings, cancers diagnosed in 2012, which are linked to diabesity are almost twice as common in women (496,700 cases) as men (295,900 cases). The combination of excess BMI and T2DM risk factors in women accounts for the highest proportion of breast and endometrial cancer: about 30% and 38% respectively. In men, the combination accounts for the highest proportion of liver and colorectal cancers. Overall, the biggest proportion of cancers linked to diabesity is found in high income western nations, such as the UK (38.2% of 792,600 cancer cases diagnosed in 2012), followed by east and southeast Asia (24.1%). 16.4% of cases of cancer in men and 15% in women in high income western nations are linked to being overweight, compared to 2.7% and 3% respectively in south Asia. Researchers suggest that on current trends, the number of cancers linked to a combination of excess BMI and T2DM could increase by 30% by 2035, which would take the worldwide total of these cancers from 5.6% to 7.35%.

Uneven prevalence of cancers resulting from diabesity

While cancers associated with diabesity are a relatively small percentage of the total - the global 5.6% masks wide national variations of cancer prevalence resulting from diabesity. For example, in high income western nations, such as the UK, 16% of cancers are linked to excess BMI and T2DM, which suggests a potentially significant trend. As known cancer risk factors such as smoking tobacco have declined in the UK and other wealthy nations, so diabesity has increased as a significant risk factor.

According to Jonathan Pearson-Stuttard,of Imperial College London and lead author of the 2018 Lancet study, the prevalence of cancer linked to excess BMI and diabetes is, “particularly alarming when considering the high and increasing cost of cancer and metabolic diseases. As the prevalence of these cancer risk factors increases, clinical and public health efforts should focus on identifying optimal preventive and screening measures for whole populations and individual patients”.

Risks of cancer and their vast and escalating costs

Clinicians, public health officials and charities are mindful of the vast and escalating risks of excess BMI and T2DM on cancer. According to Diabetes UK, 4.5m people are living with diabetes in the UK, 90% of these have T2DM, and another 11.9m are at increased risk of T2DM. Research published in the May 2016 edition of theBritish Medical Journal reports that prevalent cases of T2DM in the UK more than doubled between 2000 and 2013: from 2.39% to 5.32%, while the number of incident cases increased more steadily.

According to a 2014 report by Public Health England entitled “Adult obesity and type-2 diabetes”, the direct annual economic cost of patient care for people living with T2DM in 2011 was £8.8bn; the indirect costs, such as lost production, were about £13bn, and prescribing for diabetes accounted for 9.3% of the total cost of prescribing in 2012-13. The Report concludes, “the rising prevalence of obesity in adults has led, and will continue to lead, to a rise in the prevalence of type 2 diabetes. This is likely to result in increased associated health complications and premature mortality . . . Modelled projections indicate that NHS and wider costs to society associated with overweight, obesity and type 2 diabetes will rise dramatically in the next few decades”.

Preventing excess BMI and T2DM as a way to reduce the burden of cancer

Because of the increasing prevalence of diabesity clinicians, healthcare providers and charities have invested substantially in programs to prevent obesity and T2DM. Notwithstanding, the UK’s record of reducing the burden of these disorders is poor. According to the authors of TheLancet study, “Population-based strategies to prevent diabetes and high BMI have great potential impact … but have so far often failed.” Despite an annual NHS spend of £14bn on diabetes care, and over £20m spent annually by Diabetes UK on “managing diabetes, transforming care, prevention, understanding and support”, over the past 10 years people with diabetes have increased by 60%.

Healthier You a national diabetes prevention program

Healthier You, a joint venture between NHS England, Public Health England and Diabetes UK was launched in 2016 and aims to deliver evidence-based behaviour change interventions at scale to people at high risk of T2DM to support them in reducing their risk. In December 2017, an interim analysis of the program’s performance was published in the journalDiabetic Medicine. Findings suggest that Healthier You has achieved higher than anticipated numbers of referrals: 49% as opposed to 40% projected, and the, “characteristics of attendees suggest that the programme is reaching those who are both at greater risk of developing Type 2 diabetes and who typically access healthcare less effectively.”

Cautionary note

Notwithstanding, the study’s authors conclude with a cautionary note and say that when data become available from the 2019 National Diabetes Audit (NDA) they will be better positioned to assess the program’s performance. Specifically, whether Healthier You participants changed their weight and HbAc1 levels over time. (HbA1c is a blood test that indicates blood glucose levels and is the main way T2DM is diagnosed). We are mindful that earlier National UK Diabetes Audits suggest there are significant challenges associated with incomplete and inconsistent patient data at the primary care level, and also significant variation in diabetes care across the country. It seems reasonable to assume that incomplete and inconsistent data will present analytical challenges.

Outcomes as key performance indicators

Notwithstanding, the authors of the interim appraisal of Healthier You are right to attempt to link key performance indicators (KPI) with patient outcomes rather than provider activities, which tend to be the preferred performance indicators used by public officials, clinicians and charities engaged in preventing obesity and T2DM. At the population level, there is a dearth of data that associate specific prevention programs with the reduction of the prevalence of obesity and T2DM. Until actual patient outcomes become the key performance indicators, it seems reasonable to suggest that inertia rather than innovation in prevention and care of T2DM and obesity will prevail, and year-on-year the burden of diabesity and associated cancers will continue to increase.

Casalud

Two significant and effective innovations to reduce excess BMI and T2DM, which have been largely ignored by the UK’s diabetes establishment are the Casalud and Oklahoma City projects. Casalud is a nation-wide online continuing medical education program launched in Mexico in 2008, which has demonstrated influence on the quality of healthcare, and subsequent influence on patient knowledge, disease self-management, and disease biomarkers. Casalud provides mHealth tools and technical support systems to re-engineer how primary care is delivered in Seguro Popular (Mexico’s equivalent to NHS England) primary health clinics. By focusing on prevention and using technology, Casalud has increased the number of diabetes screenings and improved clinical infrastructure. An appraisal of the program published in the October 2017 edition of Diabetes, Metabolic Syndrome and Obesitysuggests that the Casalud program successfully impacts changes in obesity and T2DM self-management at the primary care level throughout the country.

Oklahoma city’s transformation

Oklahoma is a city of about 550,000 people. In 2007, it was dubbed America’s “fast food capital" and “fattest city". A decade later, the city was in the middle of a transformation. While the state still has among the highest adult obesity rates in the nation – climbing from 32.2% to 33.9% between 2012 and 2015 – obesity rates in Oklahoma City dropped from 31.8% to 29.5% during that time frame, according to the US Centers for Disease Control and Prevention data. The city’s transformation started with city’s Mayor Mick Cornett. Cornett, who has been in office since 2004, brought notoriety to the city’s public health efforts beginning at the end of 2007 with the goal to collectively lose 1m pounds. The people of Oklahoma City met that goal in 2012, but have not slowed down their efforts. What began as a campaign to promote healthy eating and exercise became a citywide initiative to, "rebuild the built environment and to build the city around people instead of cars," Cornett says.

Underutilized data that detect early people at risk of T2DM

Findings of a study published in the May 2017 edition of Scientific Reports suggest an innovative way to improve early diagnosis of excess BMI and T2DM when the diseases are easier and less costly to treat, but so far these data are underutilised. The study reports that increasingly people are searching the Internet to assess their health and records of these activities represent an important source of data about population health and early detection of T2DM. The study based on data from the 2015 Digital Health Record produced by Push Doctor, a UK based online company, which has over 7,000 primary care clinicians available for online video consultations. According to the study, which is based on 61m Google searches and a survey of 1,013 adults, 1 in 5 people chose self-diagnosis online rather than a consultation with their primary care doctor. The study makes use of commercially available geodemographic datasets, which combine marketing records with a number of databases in order to extract T2DM candidate risk variables. It then compares temporal relationships with the search keywords used to describe early symptoms of the T2DM on Google. Researchers suggest that Google Trends can detect early signs of T2DM by monitoring combinations of keywords, associated with searches. Notwithstanding, the value of these data they are underutilized by clinicians, public health officials and charities engaged in reducing the risks of excess BMI and T2DM, which can lead to cancer.

Takeaways

Over the past decade, NHS England has spent more than £100bn on diabetes treatment alone, and Diabetes UK has spent some £200m on education and awareness programmes, yet diabetes in the UK has increased by 60%. 90% of diabetes cases are T2DM, which is closely linked to obesity. The combination of excess BMI and T2DM causes some 16% of all cancers in the UK. The burden of these diseases destroys the lives of millions and cost billions. It is imperative that this vast and escalating burden is dented. This will not be achieved if clinicians, public health officials and charities continue with ineffective inertia projects. They will need innovate and embrace best practice if they are to prevent and reduce the vast and escalating burden of excess BMI, T2DM and cancer.

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Obesity is one of the most serious global public health challenges of the 21st century and a major cause of type-2 diabetes (T2DM), a life-threatening illness, which costs billions

60% of adults in the UK are either overweight or obese, 74% in the US

Low calorie diets and exercise are difficult to sustain and therefore tend to fail as treatment options

Conventional treatments for T2DM have failed to dent the vast and escalating burden of the condition, so interest is increasing in alternative treatment options

Bariatric (stomach reduction) surgery is a therapy for obesity, which has been shown to “cure” T2DM

In 2016, 45 international health organizations called for bariatric surgery as a treatment for T2DM

Is bariatric surgery the biggest step forward in T2DM treatment in 100 years?

Weight loss surgery to treat T2DM

It is five minutes to midnight for healthcare systems struggling in vein to reduce the vast and escalating burden of type-2 diabetes (T2DM). Doing more of the same is no longer an option. Given the lack of alternatives, experts are calling for an increase in bariatric surgery because it has been shown to “cure” T2DM.

Bariatric surgery not only reduces weight, it also improves glycemic control by a combination of enforced caloric restriction, enhanced insulin sensitivity, and increased insulin secretion with a consequent reduction in the symptoms of T2DM.

In the video below Kenneth D’Cruz, Senior Consultant Gastroenterological Surgeon at Narayana Health, India describes bariatric surgery, which refers to a range of procedures including gastric bypass, gastric sleeve, gastric band,and gastric balloon.Such procedures are often performed to limit the amount of food that an individual can consume, and are mainly used to treat those with a body mass index (BMI) of above 40, and in some cases where BMI is between 30 and 40, if the patient has additional health problems such as T2DM.

Epidemiology of obesity

Overweight and obesity are principal risk factors of T2DM. In the UK, the number of people classified as obese has doubled over the past 20 years and continues to rise. According to data from the 2014 Health Survey for England, 24% of adults in England are obese and a further 36% are overweight. In 2015, there were 440,288 admissions to England's hospitals for which obesity was the main reason or a secondary factor.

Data from the National Child Measurement Programme (NCMP), suggest 10% of children in the UK are obese by the time they start primary school, and 25% are so by the time they finish. 6% of people in the UK are living with diabetes of which 90% have T2DM. Over the past decade the incidence rate of T2DM has increased by 65%.

The situation is similar in the US, where 36% of adults are obese, and 6.3% have extreme obesity. Almost 74% of adults are considered either overweight or obese. Over the past 30 years, childhood obesity has more than doubled, and it has quadrupled in adolescents. The percentage of children who were obese increased from 7% in 1980 to nearly 18% in 2012. 9.3% of people in the US are living with diabetes.

The World Health Organization warns that obesity is, “one of the most serious global public health challenges of the 21st century”.

Causes of obesity

There are many complex behavioural and societal factors that combine to contribute to the causes of obesity. At its simplest, the body needs a certain amount of energy (calories) from food to keep up basic life functions. When people consume more calories than they burn, their energy balance tips toward weight gain, excess weight, and obesity. In the videos below Mohammed Hankir, Department of Medicine, University of Leipzig, Germany, describes what causes obesity, and the relationship between obesity and T2DM:

What are the causes of obesity?

What is the relationship between obesity and type-2 diabetes?

The cost of diabesity

Obesity costs the UK £47bn every year. The medical care costs alone for obesity in the US are estimated to be more than US$147bn. Diabetes treatment and indirect medical costs run to £10.3bn in the UK and US$176bn in the US, representing significant increases over the past five years. The medical costs for an individual with diabetes are typically 2.5 times higher than for someone without the disease. As prevalence of obesity increases these costs will rapidly rise.

T2DM prevention and treatment

NHS England, Public Health England and Diabetes UK’s National Diabetes Prevention Program is based upon diet and exercise-induced weight loss, which sometimes remedies insulin resistance. For obese people dietary and lifestyle therapies have limited short-term and almost non-existent long-term success records. According to Professor John Wilding, Head of the Department of Obesity and Endocrinology at the University of Liverpool, UK; the problem with low calorie diets, “is that most people will lose weight, but most people will also regain much of that weight that has been lost.” The UK’s National Institute of Health and Clinical Excellence (NICE) does not support the routine use of low calorie diets.

Once an overweight or obese person has T2DM the stakes change. With the limited success of conventional medical therapies, bariatric surgery has become an increasingly popular treatment in the war against obesity and latterly also for T2DM. The 2014 UK National Bariatric Surgery Registry reported that there is good evidence from randomised controlled studies that surgery is superior to medical therapy in improving diabetes control and metabolic syndrome. Surgery lowers the number of hypoglycaemic medications needed, including some people no longer needing insulin. It also means many people living with T2DM going into remission, and it markedly lowers the incidence of T2DM compared to matched-patients not having surgery.

NICE guidelines for bariatric surgery as a therapy for diabesity

Concerned about the rising prevalence of diabesity (obesity and diabetes) and the limited success of conventional strategies, in 2011, the International Diabetes Federation endorsed bariatric surgery as a T2DM treatment for obese people. The Federation’s endorsement is a validation of research and medical experience showing that surgery to reduce food intake can alter the biochemistry of the entire body. It also marked the beginning of a major new assault on diabetes.

In 2014, NICE introduced guidelines for bariatric surgery as a treatment option for obese adults, and suggested that it would greatly help T2DM. Current NICE guidelines state that bariatric surgery should be offered to anyone who is morbidly obese (a BMI of 40 or over), to those with a BMI over 35 if they have another condition, such as T2DM, and to those with a BMI of at least 30 with a recent diagnosis of diabetes.

In the UK only about 6,500 people each year have bariatric surgery. This is significantly lower than other European countries, which perform on average about 50,000 stomach reduction surgeries each year. Under the NICE guidelines, up to 2m people would be eligible for free bariatric surgery on the NHS, which would cost the taxpayer £12bn.

Biggest breakthrough in diabetes care since the introduction of insulin

In 2016 a review written by a group of researchers led by David Cummings, an endocrinologist at the University of Washington set out guidelines for bariatric surgery as a treatment option for diabetes. Francesco Rubino, one of the experts behind the guidelines and professor of metabolic and bariatric surgery at King's College London, said: “This is the closest that we have ever been to a cure for diabetes. It is the most powerful treatment to date.” Other doctors who drew up the guidelines said such changes could amount to the most significant breakthrough in diabetes care since the introduction of insulin in the 1920s.

The modern Roux-en-Y gastric bypass

The ‘gold standard’ bariatric surgical procedure is the Roux-en-Y Gastric Bypass, which is the most commonly performed bariatric procedure worldwide, named after a 19th century Swiss surgeon César Roux, who first performed the surgery to reroute the small intestine. The modern version of the procedure involves reducing the stomach to a little pouch, to curb eating and appetite, and then connecting that pouch to a lower section of the intestine. By using less of the intestine, fewer nutrients are absorbed, and the patient loses weight.

Until recently it has been poorly understood why, after bariatric surgery, a significant proportion of patients with T2DM leave hospital either needing no insulin, or lower doses, before ever losing any weight. Re-plumbing the GI-tract appears to reprogram the body’s hormones and resets its metabolism.

Advances in bariatric surgery

Thirty years ago there was little interest in bariatric surgery, which was risky, and not widely practiced. It involved a large, bloody incision, the prising apart of the heavy, fatty abdominal walls with metal arms, which then had to be held in place while the surgeon carried out procedures deep in the gut. Patient recovery times were long, and the risk of complications high.

By the first decade of the 21st century, when obesity became an epidemic in advanced economies the relationship between bariatric surgery and T2DM was given more attention. The medical device industry developed new surgical tools to facilitate blood free minimally invasive procedures for obese people, but researchers were still struggling to understand why bariatric surgery “cured” diabetes.

Understanding why bariatric surgery cures diabetes

One of the scientists to discover why bariatric surgery cures T2DM is Blandine Laferrère, an endocrinologist at the New York Obesity Nutrition Research Center at St. Luke’s. Our gut hormone ghrelin signals to our brain that we are hungry and to start eating. Receptors in out GI tract signal to our brain that we are full and to stop eating. In obese people such signalling malfunctions, and leaves them perpetually hungry. According to Laferrère, “It just happened that the surgeons did this type of surgery for weight loss, and that turned out to have a spectacular effect on the remission of T2DM.”

Further research was undertaken by Laferrère and influenced by Werner Creutzfeldt, a German doctor who published work on gut hormones that increased stimulation of insulin secretion, which he called an “incretin effect”. According to Laferrère, bariatric surgery, rather than actual weight loss, stimulates the incretin effect, which boosts the production of insulin while lowering the symptoms of diabetes. She concluded that the surgery itself triggered the hormone network, which diet-induced weight loss could not provide.

Takeaways

Scientists claim that bariatric surgery is the biggest step forward in diabetes treatment in 100 years, and suggest we are no longer talking about the treatment of obesity, but treatment of diabetes.

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The Mexican ConnectionA Special Report

People are eating themselves to death and our healthcare systems and governments are failing to stop it

Obesity and type-2 diabetes (diabesity) kills thousands unnecessarily, and threatens the stability of healthcare systems around the world

In the UK there is mounting frustration with the diabetes establishment’s failure to make inroads into the prevention and management of diabesity

Mexico is re-engineering the way primary care delivers its services in order to prevent and reduce the burden of diabesity

There are lessons from Mexico for healthcare systems challenged by the diabesity epidemic

Breaking the cycle of ineffective diabesity services

People are eating themselves to death, and our healthcare systems are failing to stop it. Not more so than in Mexico, where 70% of the population is overweight and 33% obese; both risk factors of type-2 diabetes (T2DM), which kills 70,000 Mexicans each year.

The situation is not that different in the UK, which has the highest levels of obesity in Western Europe: 64% of adults in the UK are either overweight or obese, and the incidence rates of diabetes have more than trebled over the past 30 years. Each year, in the UK diabetes kills 22,000 people unnecessarily, and leads to 7,000 avoidable lower limb amputations.

The two countries differ however in their respective responses to the epidemic of obesity and diabetes (diabesity), which is the subject of this Commentary. While the UK’s diabetes establishment appears to be locked into a cycle of ineffectiveness, the Fundación Carlos Slim (FCS), is re-engineering the way Mexico’s primary healthcare system delivers its services in order to prevent and reduce the vast and escalating burden of diabesity. The FCS’s endeavours have important lessons for the UK, and indeed other countries battling with a similar epidemic.

Diabesity a global challenge

Diabesity is no longer a disease of rich countries; it is increasing everywhere. An estimated 422m adults were living with diabetes in 2014, compared to 108m in 1980. The global prevalence (age-standardized) of diabetes has nearly doubled since 1980, rising from 4.7% to 8.5% in the adult population. This reflects an increase in associated risk factors such as being overweight or obese. Uncontrolled diabesity has devastating consequences for health and wellbeing, and it also impacts harshly on the finances of individuals and their families, and the economies of nations.

Mounting frustration with the UK’s diabetes establishment

Although there is consensus about what needs to be done to prevent and enhance the management of obesity and T2DM, and although each year NHS England spends £10.3bn on diabetes care, and £4bn to treat obesity, the prevalence rates of the conditions continue to rise, and the UK’s diabetes establishment seem unable to do anything about it.

This ineffectiveness has caused mounting frustration with the diabetes establishment on the part of the UK government’s National Audit Office (NAO) and the Public Accounts Committee (PAC). Numerous official inquiries into adult diabetes services have found no evidence to suggest that T2DM prevention and care are effectively managed, and failure to do so leads to higher costs to the NHS as well as less than adequate support for at risk people and those with the condition.

Damning official inquires into adult diabetes services

A 2015 NAO report into adult diabetes services found, “that performance in delivering key care processes and achieving treatment standards [recommended by the National Institute for Health and Care Excellence (NICE)], which help to minimise the risk of diabetes patients developing complications in the future, is no longer improving . . . . There are significant variations across England in delivering key care processes, achieving treatment standards and improving outcomes for diabetes patients, (and) . . . There are still 22,000 people estimated to be dying each year from diabetes-related causes that could potentially be avoided”.

When the Public Accounts Committee (PAC) reported on adult diabetes services in 2012 it found that, "progress in delivering the (NICE) recommended standards of care and in achieving treatment targets has been depressingly poor. There is no strong national leadership, no effective accountability arrangements for commissioners (local healthcare providers), and no appropriate performance incentives for providers." Four years later, a 2016 PAC inquiry into adult diabetes services reported that nothing of significance had changed. The Committee was concerned, “that performance in delivering key care processes and achieving treatment standards is no longer improving”, and it challenged, “the Department of Health, the NHS and Public Health England on their lack of progress in improving patient care and support”.

The UK’s cycle of ineffective diabesity services

The NAO and the PAC inquiries appear to have identified a cycle of ineffectiveness among the UK’s diabetes establishment, which manifests itself in a familiar scenario. Here is a stereotypical picture.

Each year, after the publication of the latest prevalence data for obesity and diabetes, Diabetes UK, a leading charity, “calls on the government to do more”, the National Clinical Director for Obesity and Diabetes at NHS England makes a defensive statement usually emphasising the positive aspects of diabetes services. NHS England continues to spend £14.3bn each year on the treatment of diabesity. There continues to be little improvement in the 20,000 plus unnecessary annual diabetes-related deaths, and 7,000 avoidable amputations. Diabesity services continue to be inflexible and process, rather than outcomes driven. Nothing of substance changes, prevalence rates and eye-watering costs continue to rise, and no one is accountable.

This cycle of ineffectiveness reflects a dearth of national leadership among the diabetes establishment.

The Fundación Carlos Slim (FCS) appears successfully to have broken a similar cycle of ineffectiveness for the prevention and treatment of diabesity in Mexico. The Fundación used the weaknesses in Mexico’s primary healthcare system as an opportunity to re-engineer the prevention and treatment of diabesity with an innovative program called Casalud. The name is derived from two Spanish words: “casa” (house) and “salud” (health): ‘Homehealth’.

In 2008, when the FCS launched the Casalud program, the primary care services of both the UK and Mexico were similar in in their inflexibility, and in emphasising treatment processes and service delivery rather than value-based healthcare. This emphasis results in weak primary care systems, which contribute to the increased prevalence of diabesity.

We will draw lessons from the Casalud program, but before doing so let us consider the grounds for a comparison between the healthcare systems of the UK and Mexico.

UK and Mexico compared

In both countries the prevalence of obesity and T2DM are high and increasing. Both governments’ healthcare systems are struggling to effectively cope with the vast and growing burden of diabesity. Mexico’s Seguro Popular, which is roughly equivalent to NHS England, serves about 57m people: which includes 60% - 34m - of Mexico’s poorest non-salaried workers employed in the informal sector. Mexico’s population is younger than the UK’s. The median age of Mexico’s 129m citizens is 29 years, whereas in the UK, which has a population of 65m, the median age is 40 years.

Both the UK and Mexico struggle with structural challenges associated with the supply and competence levels of health professionals. These manifest themselves in significant local variations in the effectiveness of diabesity prevention and treatment, and in lengthy waiting times for GP consultations.

Annual foot checks in the UK and Mexico

In England for instance, standard annual recommended foot checks for people with diabetes vary as much as 4Xs depending on where you live. Each year 415,000 or 13.3% of people with T2DM do not receive foot checks, which increases their risk of amputation, and fuels the 7,000 avoidable lower limb amputations carried out each year. Similarly in Mexico, 60% of people with diabetes fail to have their feet examined during primary care consultations, and between 86,000 and 134,000 diabetes-related amputations occur each year.

Responding to the recent English findings, Professor Jonathan Valabhji, the National Clinical Director for Obesity and Diabetes at NHS England said; “It is very important as many people as possible receive their foot checks at the right time – currently each year 85% of people with diabetes receive these foot checks.”

Leadership to break the cycle of ineffective healthcare servicesIn contrast to the UK’s diabetes establishment, the Casalud program provides strong, well-coordinated national leadership, and effective accountability and performance incentives for local healthcare providers. It does not however, deliver direct healthcare services; these are provided by the state. Instead Casalud concentrates on fostering the implementation and use of innovative technology, which it has designed to enhance patient centred primary care, extend healthcare into communities and homes, encourage self-management, engage in prevention programs, and enhance the competence and capacity of healthcare professionals within Seguro Popular.

For the Casalud program to stand a chance of being supported by the Mexican government, and implemented nationally, the FCS understood that it was essential to collect convincing performance data in its pilot program. From its inception therefore, the Casalud program developed and agreed with the relevant healthcare agencies a suite of performance measures, data collection protocols and reporting systems. This helped the Fundación to secure the backing of key national and regional healthcare agencies.

The FCS chose a social franchising model for the Casalud program, which uses commercial best practice to achieve socially beneficial ends, rather than profit. This makes the program significantly different to the endeavours of some UK public and non-profit bureaucracies, which provide diabesity services.

Some common aspects of bureaucracies

Here we briefly describe some common aspects of bureaucracies, which suggest that over time, bureaucratic organizations may become ineffective diabesity service providers. Bureaucracies are machine-like organizations characterised by hierarchical authority, a detailed division of labour, and a set of rules and standard procedures, which staff are obliged to follow. Rules provide a means for achieving organisational goals, but the following of the rules sometimes displaces the actual objective of the organisation, and organisational objectives become secondary. This is encouraged by the fact that people in bureaucracies tend to be judged on the basis of observance of rules and not results. For example, in an organisation, say committed to diabetes services, performance may be judged on the basis of whether expenditure has been incurred according to rules and regulations. Thus, expenditure becomes the criterion of performance measurement, and not the results achieved through expenditure. Bureaucracies almost completely avoid public discussion of its techniques, although there may be some discussion of its policies. This secrecy is believed to be necessary to prevent “valuable information” from leaking out, and going to competitors. “Trained incapacity” is a term sometimes applied to bureaucracies to describe training and skills, which have been successful in the past, but are unsuccessful under present changed conditions. Inadequate flexibility, in an evolving environment such as healthcare, will result in ineffectiveness.

mHealth platform embedded with bespoke tools

The Casalud program avoided bureaucratic traps that result in ineffectiveness by developing a flexible mHeath platform (the use of mobile phones and other wireless technology in medical care) with an embedded suite of proprietary software, which connects patients to health providers, nudges people to self-manage their own health, and to become integral members of local care teams. The platform is used for mobile screening, providing patients with their own individual healthcare dashboards, online healthcare education, supply chain monitoring, standardizing electronic patient records, and big data strategies. It also acts as an entry point for patients, support for health professionals to identify at-risk people, make early diagnosis, and quickly begin diabesity management, and structure follow-up with patients over time.

The Casalud program’s successful pilot

In 2009, the FCS began a 3-year pilot of its Casalud program in 7 Mexican states, which resulted in improved patient knowledge about diabesity, enhanced self-management among people with the condition, increased clinician knowledge of diabesity prevention and management, and improved clinical decision-making.

The FCS used performance data from its pilot to secure a partnership with the Mexican Ministry of Health to extend the Casalud program to 120 primary care clinics serving 1.3m people across 20 Mexican states - 4 to 10 clinics in each state. Also, the performance data was successful in getting the Casalud program adopted as an integral component of the National Strategy for the Prevention and Control of Pre-obesity, Obesity and Diabetes. So, within three years the Casalud program went from a relatively small charity-backed start-up to a significant component in a nationally supported healthcare system.

It is reasonable to assume that this was partly due to the leadership provided by the FCS, and partly due to setting, collecting and reporting appropriate performance indicators. The FCS acted similarly to a lead institution in a commercial endeavour, and successfully recruited key contributing partners who were prepared to share the costs of the program’s national rollout. The FCS covers the cost of all the software development, and the training of healthcare professionals for the Casalud program. All the software is owned by the FCS, and licensed free-of-charge to the Mexican government. The federal government covers the cost of all computer hardware used in participating clinics, and local state governments cover the cost of Casalud’s operations, which include such things as laboratory tests and medications.

The 5 components of the Casalud program

To better understand the Casalud program and its contribution to enhanced diabesity services we review its five components: (i) proactive prevention and detection of diabesity, (ii) evidence-based management of diabesity, (iii) supply chain improvements, (iv) capacity-building of healthcare professionals, and (v) patient engagement and empowerment. Each component has an on-going monitoring system associated with it, which informs the FCS on the status of the program’s implementation.

1. Proactive prevention and detection of diabesity

Previous attempts in Mexico at community based screening for diabesity have failed. However, the FCS insisted that a national screening strategy was important for reducing the burden of diabesity, but understood its case would need to be supported by appropriate performance data, which would require systematic collection and reporting. To help achieve this the FCS developed two online risk assessment tools, which capture, assess and report data on peoples’ risk factors of diabesity.

One of these tools is used in clinics, and the other, which is portable, used in homes and communities. Both screen and categorise people as, (i) healthy, (ii) at risk of diabesity, and (iii) already diagnosed as obese or with T2DM. Screening allows local healthcare professionals to suggest personalised lifestyle changes to individuals either to help them reduce their risk of diabesity or to improve their management of the condition. Each participating clinic has a screening goal. Screening data are collated and reported weekly on a pubic system, which incentivizes the clinics in their screening endeavours.

Having a portable device means that populations, which previously did not have access to healthcare are included in the screening. While this increased the number of reported people with diabesity, over time it lowered healthcare costs because early detection reduced the use of urgent care facilities. This proactive component of the Casalud program and the performance data resulted in the support of federal healthcare officials who saw the advantages of using technology to integrate communities, families, and patients into a continuum of care. The tools also extended care to people and communities that previously had little access to healthcare, and encouraged patients to use technology to manage their own health, which health authorities appreciated.

2. Evidence-based diabesity management

The second component of the Casalud program is an evidence-based diabesity management system, which is supported by more software developed by the FCS. This includes agreed international best practice protocols for diabesity prevention and management, a digital portfolio for health professionals, electronic monitoring of patients in order to improve the accuracy and reliability of performance measurements and patient data. Such data are used to improve the quality of clinical decision-making.

Examples of the data collected and reported are the percentages of people with T2DM and their corresponding laboratory test results. Casalud’s study found that out of 961,733 patients with T2DM, only 20% had an HbA1c (blood glucose) measurement. Further, only 40.7% of patients with an HbA1c measurement had their HbA1c levels under control (below 7%). All data are made available at the national, state and clinic levels, and are thereby expected to empower healthcare providers to base their health policy decisions on the areas of most need.

3. Supply chain improvement

Mexico like other emerging countries suffers from an inconsistent supply of medicines and laboratory tests, which is a significant obstacle to optimal disease prevention and management. Drug supply decisions in Mexico are centralized and made at a state or federal level. This is different to the UK, and other developed countries.

This component of the Casalud program uses a proprietary online information system that standardizes metrics for stock management at the clinic level to improve the supply of medicines and laboratory tests. The software is made available on mobile phones to make it easy for health professionals to ensure that stock levels are adequate for clinics to provide a quality service. In addition, Casalud uses these data to raise awareness with federal and state healthcare officials of inefficiencies in supply chains, which could fuel complications and increase healthcare costs. Prior to Casalud there was no accurate and systematic way to assess and report on the supply of medicines and laboratory tests.

4. Capacity building for healthcare professionals

Casalud’s forth component is an interactive platform to develop the capacity of healthcare professionals through online education, which leads to diplomas conferred by national and foreign universities. The FCS partnered with Harvard University’s Joslin Diabetes Center, and Mexico’sNational Institute of Medical Sciences and Nutrition to develop courses that certify competence in key areas of diabesity prevention, diagnosis and management. One course is designed to update doctors’ knowledge of diabesity, and the other is a practical course developed by faculty of the Joslin Diabetes Center in which health professionals solve real-life cases to test their knowledge in practical settings.

Certificates act as non-monetary incentives for health professionals, and to promote competition between clinics and health professionals. This helps to increase participation in the program, improve the quality of care, encourage openness and transparency, and increase collaboration between clinics.

Software developed by the FCS assists local clinics to capture data on the characteristics of the participating healthcare professionals, their baseline knowledge, and improvements after each course. These data are aggregated to choose a clinic of excellence for each state, and a national clinic of excellence; both of which are publicly recognised awards, and help with Casalud’s national rollout strategy.

Further, performance data are contributed to the National Strategy for Improving Skills and Capacity of Healthcare Personnel, which obliges all Mexican healthcare institutions to engage in formal online training that is, personalized, linked to a continuing education program, validated by academic institutions and independently monitored. Casalud’s capacity building component fulfils all of these criteria.

5. Patient engagement and empowerment

With the help of the Joslin Diabetes Center, the Mayo Clinic, and Mexico’s National Nutrition Institute, this component has two mobile applications, which assess patient engagement, knowledge of diabesity, and confidence and skills in order to help them understand their health, begin to self-monitor their condition, interpret their own results, and implement beneficial lifestyle changes. A specific app for people with T2DM allows them to schedule medicines and appointment reminders, input glucose and weight measurements, and receive immediate personalized feedback and educational messages from health professionals.

However, the FCS changed its approach following evidence from the program’s pilot, which suggested that due to the characteristics of the patient population – elderly, rural, and with limited access to and familiarity with technology – mobile technology alone would not lead to a high percentage of patient engagement. So, Casalud implemented a suite of in-person interactions and activities, which are thought to be more appropriate for the specific patient population.

Such a change may not be necessary in the UK and other developed countries. In the UK for instance, the growth trend in smartphone ownership is present in all age groups, and fastest among 55-64 year olds, which jumped from 39% in 2014 to 50% in 2015. While those aged over 55 are more likely to own a laptop the gap is closing. Among younger age groups, 90% of those aged 16-24 now owns a smartphone.

Takeaways

Although the Casalud program has encountered challenges associated with Mexico’s patchy technological infrastructure, entrenched attitudes of some health professionals, and fragmentation and lack of uniformity of its primary healthcare system; the program has been successful; not least because of its flexibility and speed of adjusting to prevailing conditions. In 2015 a Brookings Institution research paper concluded that, “Casalud has made significant strides in transforming care delivery in Mexico”.

Casalud’s development and implementation continues. It is an innovative program, which employs appropriate technology and evidence-based knowledge to re-engineer Mexico’s public sector primary healthcare system by encouraging patient self-management to reduce the country’s vast and increasing diabesity burden.

Casalud provided leadership and seed money to secure financial support from and create consensus between the federal and state governments, and obtain local support from clinics, healthcare professionals and patients. The program is on-going and warrants consideration from the UK’s diabetes establishment, and those of other countries wrestling with the burden of diabesity.